User fees are in place in most sub-Saharan African countries. They were introduced to tackle severe under-funding, but evidence shows that such fees do not generate much revenue, are unlikely to improve efficiency, and disproportionately affect poor people.

Using a simulation model, researchers in London analysed how many child deaths might be prevented if user fees were removed in 20 African countries. They calculated that elimination of user fees could have an immediate and substantial impact on child mortality, preventing an estimated 233,000 deaths annually in children aged under 5 in 20 African countries (estimate range 153,000-305,000). This amounts to 6.3% of deaths in children under 5 in these countries.

Most of these lives would be saved by increased use of simple curative interventions, such as antimalarials and antibiotics combating dysentery and pneumonia, say the authors.

However, they stress that these gains will only be sustainable if policy makers establish viable alternative financing mechanisms, which also account for increased demand for services. Replacing user fees with more equitable financing methods should be seen as an effective first step towards improving children’s access to healthcare services and achieving the millennium development goals for health, they conclude.

But in another article, Lucy Gilson and colleagues from South Africa warn that removing user fees must be carefully managed to avoid negative impacts on the wider health system. “Fee removal must be accompanied by increased national budgets for health care to protect the quality of health care in the face of increased utilisation,” they write. And they also emphasise the need to engage key groups such as health workers in the implementation of this policy change.